Factors associated with unsuccessful pessary fitting in women with symptomatic pelvic organ prolapse: Systematic review and metanalysis.

AIMS To identify the factors associated with unsuccessful pessary fitting and reasons for discontinuation for women with symptomatic pelvic organ prolapse (POP). METHODS This systematic review is registered at the PROSPERO database. We have included all studies, regardless of the study design whose primary outcomes were factors associated with unsuccessful pessary fitting and discontinuation for symptomatic POP women. Exclusion criteria were case series, literature reviews, other forms of conservative treatment. Data selection/extraction was performed by two investigators. For pessary fitting, a meta-analysis was performed for at least two studies pooled in a forest plot. The risk of bias was classified by the ROBINS-I and ROB-2 classification. RESULTS From 409 studies retrieved after data search, only twenty-one articles remained for final analysis (18 cohort studies, 1 cross-sectional study, and 2 RCTs). Meta-analysis was performed in nine studies for pessary fitting and the associated factors were: higher body mass index (BMI) (MD = 0.688 [0.233-1.143]; P = .03; i2  = 0%), previous reconstructive surgery (OR = 1.705 [1.016-2.860]; P = .043; i2  = 69%) and advanced POP (OR = 4.2 [2.9-6.1]; P < .05; i2  = 92%). Older age, larger total vaginal length (TVL), and genital hiatus and previous hysterectomy were not associated factors. Regarding discontinuation, thirteen reasons were quoted, and the most frequent were: the desire for surgical treatment (111/3.601), pessary extrusion (385/3.601), and pain/discomfort (163/3.601). CONCLUSION Obese, previously reconstructive pelvic surgery, advanced prolapse are at risk for unsuccessful pessary fitting. Pain is the most quoted reason for discontinuation. These pooled data may help clinicians to identify patients that may not succeed in their attempt for pessary treatment.